Perspectives on healthy eating practices and acceptance of WIC-approved foods among parents of young children enrolled in WIC

Introduction The prevalence of childhood obesity remains high in the United States, particularly among children living in low-income households. Diet quality plays an important role in obesity prevention, particularly among mothers as they serve as role models. Those served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receive nutrient-rich foods aimed at increasing diet quality, yet redemption is low. Digital interventions targeting WIC parents show potential for behavior change and could be used for childhood obesity prevention. Methods This study describes the formative research conducted to understand perspectives on healthy eating practices, acceptance of WIC-approved foods, and preferences for the use of digital tools to improve the purchasing and consumption of WIC-approved foods to improve diet quality. In-depth interviews were conducted with 13 WIC parents and caregivers. Results A variety of definitions for and misconceptions about healthy eating exist among WIC caregivers. Most purchased foods were fruits, vegetables, milk, cheese, and eggs and the least purchased foods were yogurt and peanut butter. The biggest facilitator for purchasing WIC-approved foods was the preference of children and caregivers, whereas the biggest barrier was children’s picky eating behaviors. Most caregivers reported using their phone to get nutrition information. Most caregivers reported their interest in receiving weekly text messages and indicated preferences about receiving recipes. Conclusion A text messaging program that includes sending weekly messages, recipes, and nutrition tips is hypothesized to improve diet quality and increase redemption of WIC-approved foods.


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Introduction
Nearly 20% of children in the U.S. have obesity, affecting 14.4 million children [1].
Childhood obesity puts children at a higher risk of developing metabolic syndrome, type 2 diabetes, kidney diseases, and cardiovascular diseases later in adulthood [2,3].
Childhood obesity is also associated with stigma, depression, anxiety, lower self-esteem, school absenteeism and poorer academic performance [4][5][6].These long-and short-term implications underscore the importance of preventing childhood obesity.Studies show that family-based interventions, especially those targeting mothers, can be facilitators of decreasing childhood obesity from the early stages of child development [7][8][9].Mothers heavily influence their child's intake, as they are often gatekeepers of food in the home.
They play a critical role in their children's eating behavior through role modeling, creating food associations, and providing access to certain types of food [10,11].
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves pregnant, postpartum, and breastfeeding women, infants, and children up to age 5 years who live in low-income households.WIC provides vouchers for healthy foods; nutrition education; breastfeeding support; and medical and social-service referrals [12].
A hallmark of the WIC program is the food packages which are designed to meet the specific nutritional needs of WIC beneficiaries and align with national dietary guidance.
The food packages include vouchers for nutrient rich foods like fruits and vegetables, low-fat/skim milk, and whole-grain products.Studies show that participation in WIC positively influences diet quality and rates of overweight and obesity [13,14].However, WIC has experienced a decline in enrollment, retention, and food package redemption over the past decade [15,16].In addition to structural barriers associated with enrollment, dissatisfaction with the retail experience and confusion over which products are included contribute to decreased redemption of WIC-approved foods [17,18].However, little is known about how WIC participants view healthy eating and how WIC-approved foods are, or are not, embedded into the family diet.Given the impacts WIC has on childhood obesity and diet quality, efforts are needed to support the reach and satisfaction of WIC participants to maximize program efficacy.
Smartphone ownership is ubiquitous in the U.S. and particularly high among those living in low-income households [19][20][21].Digital interventions that focus on parents' behaviors, specifically mothers, have proven to be efficacious and have a positive impact on childhood obesity [22][23][24].Yet few have aimed to improve diet quality, particularly among low-income populations [25].Thus, this study describes the formative work conducted to develop a digital behavioral intervention for parents and caregivers enrolled in WIC to improve maternal diet quality by supporting redemption of WIC-approved foods [26].To ensure the intervention is congruent with the needs of WIC parents and caregivers, we conducted in-depth interviews to guide the development.These interviews focused on highlighting barriers and facilitators to consuming WIC-approved foods and behaviors associated with healthy eating.The aim of this paper is to describe findings from the formative research and provide guidance for future intervention development.

Materials and methods
The 21-item Standards for Reporting Qualitative Research (SRQR) checklist (S1 Appendix) was used to ensure transparency in conducting this research and reporting its results.

a. Recruitment
Recruitment focused on WIC participants receiving benefits from a network of federally qualified health centers that serves medically vulnerable patients throughout central North Carolina.Specific details on the recruitment procedure are reported elsewhere [26].
Briefly, WIC parents and caregivers were recruited by WIC clinicians during their regularly scheduled appointments.WIC clinicians recorded contact information for interested WIC parents (i.e., participants) using an online study form securely stored in a password-protected Box folder that could only be accessed by the research team.The research team followed up with those who were interested and assessed eligibility.If eligible, the parent completed an online consent form and baseline survey and scheduled a date and time for the interview.

b. Participants
Recruitment occurred from May 2020 through August 2020.Eligibility criteria included the following: parent or caregiver with a child 2 years old or younger, receiving benefits from WIC, have a cell phone that can receive text messages, and are English speakers.
We enrolled 13 parents and caregivers of children receiving WIC benefits.A larger sample size was planned, but we faced significant recruitment challenges due to the COVID-19 pandemic.Though the sample is small, prior work demonstrates it is sufficient for understanding common perceptions and experiences among a relatively homogenous group [27].The flow of participants through the formative research is presented in Fig 1.We conducted in-depth, semi-structured interviews [28] to obtain detailed information on a set of topics and explore food preferences and habits [29,30].An interview guide was developed by MCK, the principal investigator, with input from stakeholders including WIC clinicians and content experts in qualitative research.The interview guide consisted of open-ended questions related to redemption and use of foods received in WIC packages; thoughts about and practice of healthy eating; and WIC's role in promoting healthy eating.Other questions included thoughts about digital interventions (see Table 1).

d. Analysis
We used an in-depth reflexive thematic approach to data analysis to identify, analyze, and report themes within data [31].Mostly structural codes were used to create a codebook containing 14 sub-themes clustered into four themes.NH and MCK each independently coded the interviews using NVivo12 [32].Although inter-coder reliability is discouraged with the reflexive thematic approach, we conducted it to assess the need for improvement in the quality and credibility of the coding process [33,34].Any individual code that had a kappa below 0.81 [35] was reviewed as a team and every discrepancy was discussed and corrected.This was feasible given the small sample size.Agreement was met on every code and the final overall kappa was 0.96.

a. Description of the sample
Most of the participants were the child's mother (n=12); 1 was the grandmother (Table 2).Participants had a mean age of 31 years (range 23 -45), approximately two thirds (n=8) identified as white, with one identifying as white and Hispanic/Latina; the remaining five participants identify as non-Hispanic Black.About half (n=7) had some college education or obtained a college degree, with five participants graduating from high school.

Theme 1: (Un)healthy Eating
Participants defined their perspectives of healthy and unhealthy eating, their sources of nutrition information, and how they practice healthy eating.

Healthy eating definitions and practices
Healthy eating has different definitions according to different individuals.About half (n=6) reported that daily consumption of fruits and vegetables encompasses healthy eating.Other definitions included portion control; moderation; balance and variety of foods when eating; eating fresh, unprocessed, organic and/or whole foods; eating proteins; whole grain foods; eating foods that help with digestion; and staying hydrated.

If you know how to control it and you don't intake too much junk food. It is not hard
to have a healthy diet and enjoy some junk foods every once in a while.(29-yearold, white mother) a 30-year-old, white and Hispanic/Latina mother, said "Canned food is very high in sodium.Sodium is not good for your body." Other examples of unhealthy food definitions included fast foods (n=4), and overconsumption of any foods (n=2).One 45-year-old, white grandmother reported whole wheat foods as unhealthy, believing it raises blood glucose and insulin levels.
Another participant reported foods that are labeled as "light" as unhealthy because of their aspartame content.
About half (n=6) reported avoiding high salt and processed foods, frozen meals, and high sugar foods and beverages.Other practices included avoiding junk food, reading food labels, and diluting juices.

I thought that I was getting something healthy because it was a little snack bar for my son and then I looked at the sugar and it was like 25% of your daily value and
it was just such a small little snack bar.And I was like, "Oh my gosh, this is really bad." (27-year-old, white mother)

Source of nutrition information
Participants highlighted many different sources for getting information about nutrition, healthy eating, and meal preparation.Many participants (n=7) reported obtaining their nutrition information from online resources such as Google, YouTube, Pinterest, and Facebook.Some (n=5) also referred to WIC nutritionists who would talk about healthy eating during their appointments or refer them to resources that help with meal preparation.Other cited recipes, friends and family, food labels, partners, cooking shows, and research.One participant also mentioned that she is her own source of information because she relies on her common sense.

Devices used to get information about healthy eating
When asked if they use their phone, computer, or tablet to get information about healthy eating, many (n=7) mentioned using their phones for convenience and ease.Some (n=4) mentioned using their computers, along with their phones, except for one participant who reported using her computer exclusively.Only one participant mentioned using a tablet, along with her phone and computer.

I just use my phone for everything… Yeah, it's just easier, it's right in your hand.
(29-year-old, white mother)

Theme 2: Purchase of WIC-approved foods
Participants reported the least and most purchased WIC-approved foods, and the barriers and facilitators, respectively, affecting these purchasing behaviors.

Most purchased foods and facilitators to these purchases
Fruits, vegetables, milk, cheese, and eggs were the most purchased WIC foods as presented in the order in table 3.

Table 3. Most purchased WIC-approved foods (n=13).
The most cited reason for purchasing these foods was that the foods are used or liked by the children and/or themselves.Other reasons included that the foods are healthy, tasty, and free, and that there are many options that are provided such as lactose free milk and soy milk.As a 30-year-old, white and Hispanic/Latina mother said, "Because it's healthier eating for me and my kids."

Least purchased foods and barriers to these purchases
Yogurt and peanut butter were reported as the least purchased foods as presented in table 4.

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The biggest barrier for purchasing WIC-approved foods was that their children are picky eaters and dislike the foods (n=8).Only 2 participants reported not purchasing WIC-approved foods because they dislike those foods.Other barriers included the low amount of money allocated for purchasing fruits and vegetables; small in-store labeling; big food sizes leading to food waste; children's health conditions; limited options of WIC-approved foods; the negative health effects of some of WIC-approved foods (e.g., juice); and the unfamiliarity to cook certain foods.

Theme 3: WIC's role in healthy eating
When asked about the role WIC plays in promoting healthy eating, participants presented a variety of ideas as well as how WIC helps with other matters.

WIC's helpfulness in promoting healthy eating
All participants believed that WIC helps them eat healthier because WIC provides only healthy foods in their food packages.
It gives access to some healthy items that we need daily.(29-year-old, white mother) Another reason reported was that WIC nutritionists are nice and helpful; they are a great source for credible nutrition information about healthy eating and they sometimes help refer participants to other resources that can provide them with recipes, snack ideas, and physical activity recommendations.I've never met anybody that was not that nice and did not sit there and listen to me and hear me out.(29-year-old, white mother) The third most cited reason was WIC's resources, including educational pamphlets, shopping guide, MyPlate, and food models, which help with portion control.
Other reasons included that WIC allows participants to try new food items such as soy milk and lactose-free milk that they wouldn't buy otherwise.

Yes [it's helpful], because it [WIC] gives you a lot of information and a lot of resources if you have questions. (29-year-old, Black mother)
Two participants shared that although they consider WIC to be helpful in promoting healthy eating, they think WIC can do better.That is because although WIC offers healthy foods, they do not offer guides to help them cook or use these foods.As one 34-year-old, Black mother shared, nothing can help one eat healthy unless they are willing to: "It's just a mind over matter thing for me as far as how I'm going to eat healthy because I can eat healthy without WIC or with it…" Another participant believed that WIC does not offer healthy foods as she believes that whole wheat foods are not healthy.

Other benefits of WIC
Few participants (n=3) mentioned that WIC is helpful in ways others than promoting healthy eating.Some noted that WIC helps by providing formula which is expensive, breastfeeding classes, and ways to address their children's picky eating or feeding transitions.
That [Formula] is definitely a blessing to me because a can of milk is expensive… But also the lady [WIC nutritionist] that I go to, she gives me like different eating habits and when to know how to transition from the bottle to the sippy cup.So, those are helpful.(34-year-old, Black mother)

WIC's material vs general online material
Six participants commented on the comparison between the material WIC offers (e.g., its website, physical material such as brochures, and appointments with WIC nutritionists) and online material (e.g., Google).Two of these participants could not make a comparison, because they do not use WIC's material.

I haven't really explored it [WIC's website] to even understand it may have
recipes on there or it may have other things that I could use for dinner.(34-yearold, Black mother) Two believed that WIC is more helpful because you can get answers during your appointment with WIC nutritionists and because WIC focuses more on healthy food items compared to online material.I guess some of the stuff that a nutritionist does, I could also just look up online on different blogs for toddlers and babies.So it's not really that different but it's a little more helpful to have a conversation with someone.(27-year-old, white mother) Two believe that online information is better, because although WIC provides healthy foods, online sources provide information on how to utilize them.
They give me just the staple foods, whereas online would give me a little bit more information on how to make things, portion sizes, stuff like that.(23-year-old, white mother)

Ways WIC can help
Five participants said they wish WIC could provide them with more money for fruits and vegetables to help them last for the entire month.Of note, during the pandemic, but after these interviews were collected, WIC increased the fruits and vegetables benefit from $7-11 to $24-47 per month [36].
With my WIC package, I only get $9 for fruits and vegetables.And I mean, in this day and age, that's not really a lot to do with what fruits and vegetables you can get.(27-year-old, white mother) About half (n=5) also said that WIC can help by providing more food options such as almond milk or vegetable smoothies and healthier cereals.Other wishes were that WIC could send recipes to parents, update their pamphlets, offer organic options, focus more on parents, offer smaller sizes of foods, offer proteins such as chicken, and instruct stores to have bigger labels.
feel like it's overwhelming, but I think it would be a good idea.(39-year-old, Black mother) Two participants compared receiving text messages to emails and believe that receiving texts is easier than emails.
A lot of times people don't check their emails so I feel the texts would be more accessible.(27-year-old, Black mother)

Content of the program
Most (n=8) wanted recipes and some specifically mentioned healthy, inexpensive, and quick recipes or recipes for foods in season.The second most common content reported was tips and nutrition suggestions for both kids and parents (n=6).Other ideas included giving examples of health benefits of foods provided in WIC packages, healthy eating habits that parents can follow, portion control, moderation, balance in meal preparation, motivational messages, research, and anything that is considered informational.

Discussion
Interviewing a sample of caregivers of young children enrolled in WIC provided perspectives on healthy eating practices, preferences of WIC-approved foods, and ways WIC can improve support for healthy eating that can be used to guide future programs.
The results demonstrate a variety of definitions for healthy (and unhealthy) eating that exist among caregivers participating in WIC.These definitions also contribute to individuals' practices of healthy eating as supported by previous research [37,38].
However, surprisingly, in our sample only about half of participants reported eating fruits and vegetables as part of healthy eating practices.Results also highlight a variety of sources used to find nutrition information.These results confirm the need to understand perspectives on healthy eating to help in creating and delivering messages to inform behavior change [38,39].
Uncovering the most and least purchased WIC-approved foods helps determine what WIC foods should be focused on to increase redemption rates and maximize program efficacy while developing the intervention.The most purchased food items identified were fruits, vegetables, milk, cheese, and eggs.The least purchased food items were yogurt and peanut butter.Our results are in alignment with a study conducted in 2018 that showed foods redeemed the most were milk, fruits, vegetables, and eggs and the foods redeemed the least included, beans, peanut butter, and whole grains [40].Although our study had a smaller sample size, we identified cheese as another often purchased food and yogurt as one of the least purchased foods as opposed to whole grains.Using these results, future studies can focus on those foods participants are least likely to redeem by providing recipes and creative uses for such foods in meal and snacks throughout the day.
The biggest facilitator for purchasing WIC-approved foods was the preference of children and caregivers.However, the biggest barrier was children's picky eating behaviors.This underscores the importance of addressing this reoccurring child behavior.An expert panel report by the Healthy Eating Research national program suggests following these approaches to help address picky eating: parental modeling of healthy consumption, availability of healthy foods in the house, having family meals, and promoting food acceptance through repeated exposures to foods [41].WIC can help by providing anticipatory guidance and education about these barriers and how to overcome them via educational material, communication during appointments with WIC nutritionists, and raising awareness about these barriers with providers who refer people to WIC.
Another barrier to full redemption of WIC-approved foods identified in this study is caregivers' dislike of some foods.Research has shown that the lack of flexibility in food packages to match individual preferences often results in benefits left unspent [42].Other barriers include small in-store food labels, receiving excess amounts of foods, and unfamiliarity with certain foods' preparation.These findings align with those identified in recent studies [42,43].Another barrier to be considered is in-store grocery shopping during the COVID-19 pandemic; online grocery shopping has increased tremendously as a way to decrease transmission and adhere to safety precautions [44,45].However, there is no equitable access to online grocery shopping for WIC participants and structural changes to the WIC program are needed to make it more accessible to participants and optimize their shopping experience [46,47].
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Fig 1 .
Fig 1. Consort diagram describing flow of participants through the formative research of healthy eating Cooking methods WIC's helpfulness in healthy eating promotion Source of nutrition information Text Messaging Helpfulness of text messaging Frequency of receiving text messages Digitally audio-recorded interviews (n=13) were conducted between June and September 2020.The interviews were on average 25 minutes long (range 13 to 39 minutes).All interviews were conducted by trained researchers.Participants were compensated with a $25 Walmart gift card.All interviews were transcribed by a professional transcription agency and verified for accuracy.All study procedures were approved by the ethical review board at Duke University.
new ideas of what to make with the food.(27-year-old, white mother)Frequency of receiving text messagesWhen asked about the frequency of the text messages, most (n=10) preferred to receive text messages once a week, as frequencies more than once might get overwhelming.Around half (n=5) suggested receiving text messages in the morning, which could serve as a reference if they go grocery shopping later or to get ideas for what to cook for dinner.They can also read the messages while they're on their way to work.Just because I'm up.I have to work.So, I am constantly doing things.I may not have time to even talk, but I can look at my phone and read an articleahead of time versus at night, taking care of her.It's more of a downtime.(34-year-old, Black mother) So I have time to think about during the day and then I'd be able to think about a dinner plan.(23-year-old, white mother)

Figure 1 :Figure
Figure 1: Consort diagram describing flow of participants through the formative research Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationPowered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation